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18.07.18

Paul Farmer: What next for mental health?

Source: NHE July/August 2018

Paul Farmer, chief executive of Mind, was the independent chair of the NHS Mental Health Taskforce that produced the Five Year Forward View for Mental Health (FYFVMH) and is currently chair of the Oversight and Advisory Group which oversees the NHS recommendations. Here, he considers the future of the sector.

The recent NHS funding settlement and, with it, the directive from government to develop a 10-year plan for how it will be allocated, presents both a challenge and an opportunity for mental health services. As we approach the midway point for the FYFVMH, it’s time for serious thought and planning for what comes after 2020-21. 

The announcement of a 10-year NHS plan with significant investment means that the chance to build upon the FYFVMH has come sooner than expected. It’s important that this doesn’t result in shifting the established goal posts – not least because the existing plan was developed in consultation with over 20,000 people with experience of mental health problems and/or services, something the NHS is unlikely to be able to replicate as it develops its 10-year strategy. The FYFVMH must be delivered in full, and a longer-term plan viewed as a key opportunity to build, with much more ambition, on the work that’s already been done.

The current plan was the minimum needed to prevent catastrophic failure of mental health services. Progress has been good in some areas, mixed in others. There has, for example, been a welcome expansion in access to specific services, thanks to the roll-out of the perinatal pathway, talking therapies for people with long-term conditions, community eating disorder services, Early Intervention in Psychosis, and Individual Placement and Support. These services mean many thousands of people have been able to access support who wouldn’t have done otherwise. 

The FYFVMH has above all provided an unprecedented focus on mental health across the NHS, with greater buy-in from senior leaders and increased resource at an operational level. That said, CCG engagement with the FYFVMH has been varied, and it is not clear whether local areas are implementing it in full or picking a few areas to take forward. 

Two main issues have dominated the debate about progress: funding and workforce. Despite commitments around additional funding, there remain concerns about the level of investment reaching frontline services. The inclusion of the Mental Health Investment Standard in the latest mandate sends a strong signal to CCGs about expectations, but we know some CCGs still do not plan to meet it. 

Confidence in funding is particularly critical to tackle workforce shortages. It will require a concerted effort across the system using all possible levers to secure the workforce needed to expand access to mental health services. Crucially, the NHS needs to attract people to working in mental health and keep them motivated to stay there. The strain in mental health services means that, at the moment, experienced people are leaving – at a time when there actually needs to be enormous growth.

A 10-year strategy will need to build on the progress made and lessons learned, and should be truly transformational. As public attitudes towards mental health improve, thanks largely to the groundbreaking Time to Change campaign to end mental health stigma and discrimination, public expectations have grown. Not only are more people coming forward to ask for help, but they now expect the same access to high-quality support for their mental health as they do for physical health.

The Institute for Fiscal Studies (IFS) recently estimated that if the ambition were to provide mental health services to 70% of those who need them by 2029, spend would need to more than double over the next 15 years to £27bn. This is the scale of the challenge facing the NHS. Given the historic underfunding of mental health services, mental health should receive a disproportionate share of the new settlement. According to the IFS, mental health only gets 9% of the overall NHS budget. We are a long way from the ‘parity of esteem’ we have been promised for many years now.

A longer-term vision

Prevention is going to be key in the coming years. Only a third of people with mental health problems are accessing any kind of help and support, and demand is rising. Focusing on prevention is the only way to stem the flow and needs to include investment in public health, targeted community programmes (with a particular focus on inequalities), schools, workplaces, and an all-ages strategy to tackle loneliness. Suicide prevention also needs to remain high on the agenda, building on the recent development of local multi-agency suicide plans. 

Momentum around increasing access to treatment and support must be kept up for both the NHS and social care, offering early intervention, high-quality crisis services, and integrated services wherever possible and appropriate. Access and waiting time standards have been proven to focus minds on delivery, so these should be extended to support new pathways. 

The workforce should be expanded, with improved mental health training and better mental health support for staff, especially for GPs (since 40% of GP appointments involve mental health). Alternative, evidence-based, non-clinical interventions (such as crisis houses and social prescribing initiatives) should be mainstreamed, particularly in children and adult mental health services. There also needs to be a focus on supporting people with complex needs, including substance misuse, homelessness and offending behaviour.

Too often, the focus is on addressing an immediate crisis, and opportunities to look at longer-term recovery (and in turn prevent future crises) are missed. Services should be more ambitious and work together to take a whole-person approach. Mental health and community services need to address the different aspects of a person’s life, including housing, finances, employment, relationships, isolation, and so on, all of which have a significant impact on mental health. 

The FYFVMH identified significant problems around equalities, yet little progress has been made. There should be a fully embedded equalities framework throughout any longer-term strategy, in addition to specific programmes to address inequalities among groups with higher prevalence of mental health problems and worse outcomes (which include BAME groups, people with complex needs, people with experience of trauma, pregnant women and new mums, young people, older people, and people living in poverty). 

Overall, there needs to be a genuine commitment to making both the development of the next strategy and its delivery (nationally and locally) transparent. The publication of the mental health dashboard signalled a positive step forward towards genuine transparency on the performance of local services. While its publication has often been delayed and challenges remain around the quality of data, it has to be seen as the foundation for further openness and transparency across the mental health sector. 

We need even more information on what local areas are spending on mental health and, more importantly, we need much more data on how this is achieving better outcomes for people.

The conversation about mental health services – both publicly and within services – is heading in the right direction. With proper resourcing and a commitment to do better than just the minimum, the opportunity is there for the NHS to build mental health services that we can be proud of and that will carry us into the future. 

The success, as ever, will be in the experiences of people with or at risk of mental health problems. Until people feel they are getting the help and support they need, the job is far from done.

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